workup at blood centre components issued transfusion summary criteria for massive transfusion goal of massive transfusion Indication protocol for massive transfusion for whole blood, prbc, ffp, cryo, platelets Targets of resuscitation in massive blood loss Complications of Massive Transfusion citrate toxicity lethal triad

1. A Case of Massive Transfusion in P1L1
Post LSCS PPH Patient
In Integration with Dept. of Anaesthesiology and
Obstetrics & Gynaecology
Presenter- Dr. Shiny K. Kajal
PG-JR 1, Dept. of IHBT

2. Requisition
First requisition of 3 PRBCs, 4 FFPs and 6 PCs was received on 29.08.2023 at 1.10 am

3. Workup at Blood Centre
◦ ABO-Rh typing- B positive
◦ Hb on First Requisition- 6.2 g/dL
◦ The issue slip for PRBC and FFPs were received there and then, EMR Components were
arranged within average Turn-around Time of 15-25 minutes
◦ The issue slip for PCs was not received until next 12 hours

4. Components Issued on 29/08/2023
Date Time of
Requisition
Time of issue Component Total volume
transfused (ml)
29/08/2023 1.15 am 1.42 am 1 PRBC 393
29/08/2023 1.15 am 1.54 am 1 PRBC 398
29/08/2023 1.15 am 2.09 am 4 FFPs 811
29/08/2023 7.35 am 8.20 am 6 FFPs 1758
29/08/2023 1.15 am 2.35 pm 3 PCs 215
29/08/2023 2.25 pm 3.25 pm 1 PRBC 365
29/08/2023 1.15 am 5.10 pm 3 PCs 195
29/08/2023 5.42 pm 6.25 pm 4 FFPs 726
29/08/2023 6.05 pm 6.45 pm 1 Cryoprecipitate 40
No
Donations
About 17 hours 3 PRBCs, 14 FFPs
6 PCs, 1 Cryo
= 24 components
4901 ml
within 17 hrs

5. Components Issued on 30/08/2023
Date Time of
Requisition
Time of issue Component Total volume
transfused (ml)
30/08/2023 8.20 am 9.04 am 1 PRBC 389
30/08/2023 9.25 am 10.50 am 2 PRBC 750
30/08/2023 10.35 am 11.14 am 4 FFPs 838
30/08/2023 5.00 pm 6.15 pm 1 PRBC 360
30/08/2023 5.00 pm 7.10 pm 1 PRBC 360
30/08/2023 5.00 pm 7.30 pm 4 FFPs 740
30/08/2023 6.15 pm 7.30 pm 1 PRBC 380
No
Donations
About 10 hours
6 PRBCs, 8 FFPs
= 14 components
3817 ml
within 10 hrs

6. Components Issued 31/08/23 to 01/09/23
Date Time of
Requisition
Time of issue Component Total volume
transfused (ml)
31/08/2023 5.40 pm 6.20 pm 4 FFPs 795
31/08/2023 5.58 pm 7.01 pm 2 PRBC 750
31/08/2023 7.55 pm 8.14 pm 2 PCs 140
31/08/2023 8.25 pm 9.00 pm 4 FFPs 765
01/09/2023 5.58 am 7.00 am 1 PRBC 370
02
Donations
About 13 hours 3 PRBCs, 8 FFPs
2 PCs
= 13 components
2820 ml
within 13 hrs

7. Transfusion summary in 72 hours
GRAND TOTAL 51 UNITS
Total Packed Red Cell units issued 12
Total Fresh frozen Plasma units issued 30
Total Platelet Concentrate units issued 08
Total Cryoprecipitate units issued 01
Total Fresh Whole Blood units issued 00
Total Volume of Blood components 11538 ml

8. ◦ .On further requisitions, Hb of the patient- 5 to 8.4 to 4.2 to 5.6 to 7 to 9.4 g/dL
◦ All units were issued with Compatibility testing through Immediate Spin Cross Match
and were screened negative for HIV, Hep B, Hep C, Malaria & Syphilis
◦ In 72 hours, Donations were arranged by requesting active NGOs and repeated
announcements. Donations made by family were 02.

9. ◦ Blood Volume Of Patient Calculated By Nalder Equation- 3196 mL
◦ As Total Blood volume transfused was 11538 ml- It accounts for replacement
of nearly 3.6 Blood volumes of the patient in 72 hours and 1.5 Blood Volume
in first 24 hours of transfusion therapy- which implies to Evident episode of
Massive Blood Transfusion in the Patient

10. Massive Transfusion- Criteria
Massive transfusion is defined as the administration of -
8 to 10 red blood cell units to an adult patient in less than 24 hours
or acute administration of 4 to 5 units within 1 hour
or replacement of patient’s entire blood volume in 24 hours
or replacement of more than 50% of the circulating blood volume within 3 hours.

11. THE CLINICAL POLICY-
◦ In 1 pack- Transfusion of Fresh Frozen Plasma (FFP), then
platelets, and then RBCs in a 1:1:1 ratio
THE GOAL OF TREATMENT-
 is to restore blood volume rapidly to a level adequate to
a) maintain hemostasis (management of bleeding and
coagulopathies)
b) oxygen-carrying capacity (tissue oxygenation)
c) oncotic pressure (volume status)
d) biochemical parameters (acid-base balance)

12. Indication protocol for massive transfusion
1. F.W.B/Packed red cells
 Acute loss of blood/ Massive hemorrhage
 polytrauma, major surgeries, GI bleeds, obstetric haemorrhages
2. Platelet concentrate
 platelet count is less than 50,000/uL
3. Fresh frozen plasma
 prothrombin time (PT) ratio is greater than 1.5
 or the international normalized ratio (INR) is greater than 1.5,
 or the activated partial thromboplastin time (aPTT) exceeds 60 seconds
4. Cryoprecipitate
 the fibrinogen level is less than 100 mg/dL.

13. Targets of resuscitation in massive blood loss
• Mean arterial pressure (MAP) around 60 mmHg
• Systolic pressure 80-100 mmHg
• Hb 7-9 g/dl
• INR <1.5; activated PTT <42 s
• Fibrinogen >150-200 mg/dL
• Platelets >50000/uL
• pH 7.35-7.45
• Core temperature >35.0°C

14. Complications of Massive Transfusion
The complications of massive transfusion include dilutional coagulopathy,
hypothermia, citrate toxicity, and electrolyte disturbances
1. Citrate Toxicity- causing Hypocalcemia which can further lead to perioral and
peripheral tingling, fasciculations, hyperventilation and can also
depress cardiac function .
2. Transfusion Associated Circulatory Overload (TACO)
◦ Acute increase in intravascular blood volume
◦ Circulatory overload increases central venous pressure, causes congestion of the
pulmonary vasculature, and decreases lung compliance, manifesting as dyspnea,
tachycardia, acute hypertension, pulmonary edema and heart failure

15. 3. Hemostatic Abnormalities in Massive Transfusion- hypothermia, metabolic acidosis, coagulopathy
4. Air Embolism- can be fatal if air enters > or if air enters a central catheter while
containers or blood administration sets are being changed
5. Metabolic changes- like hypokalemia, hypomagnesemia
6. Immune complications like Acute lung injury (TRALI), Transfusion associated dyspnoea (TAD).
 The lethal triad of Massive Transfusion consists of hypothermia, acidosis, and coagulopathy
Hypothermia during massive transfusion has been shown to induce cardiac arrhythmia and arrest.

16. Special Considerations
◦ Early administration of fresh frozen plasma (FFP) during massive transfusion
decreases coagulopathy and improves survival in patients.
◦ Medical management by Drugs eg. tranexemic acid may be useful in bleeding
complicated by fibrinolysis. This avoids unnecessary fluid overload in the patient.
◦ Adjacent Calcium supplementation to avoid citrate toxicity.
◦ Invasive arterial pressure and temperature monitoring. (use of In-line warmers)
◦ Autologous transfusion in case of massive acute blood loss is being implemented.

17. REFERENCES
◦ Rossi’s Principles of Transfusion Medicine, Edition 4
◦ AABB Technical manual 18th edition
◦ Harmening DM. Modern Blood Banking & Transfusion Practices 7th edition
◦ Makroo RN. Principles & Practice of Transfusion Medicine 2nd edition